Introduction
Ocular trauma represents one of the most significant causes of visual impairment in children and is a leading cause of monocular blindness in the United States (1,2). Among the various causes of pediatric ocular trauma, toy guns with projectiles have emerged as a particularly concerning and preventable source of injury. Between 1990 and 2012, approximately 47,000 children received emergency department (ED) treatment for toy gun-related ocular injuries (TGOIs) (3). The severity and long-term consequences of TGOI cannot be understated, as they can lead to hyphema, traumatic cataracts, open globe injuries, retinal damage, or permanent visual impairment (4). The developmental implications are particularly important as any ocular injuries can not only result in permanent vision loss but also affect psychological, social, and emotional outcomes, along with economic burdens for affected children and their families (5,6).
While these injuries are concerning, research consistently shows that approximately 90% of pediatric ocular injuries are preventable with appropriate safety measures (7-9). Surveillance data from the U.S. National Electronic Injury Surveillance System (NEISS), which has been used in prior research on ocular injuries in both children and adults (10,11), provides a valuable resource for the study. Given that pediatric ocular injuries pose a public health concern, there is an urgent need for comprehensive epidemiological research to better understand current trends and to inform evidence-based prevention strategies. We aimed to examine injury incidence, demographic changes, and injury diagnosis patterns of TGOI in pediatric population using the 2005-2024 NEISS data to inform targeted prevention efforts and reduce the burden of these devastating yet preventable injuries.
Methods
Data were obtained from the NEISS, a public database launched jointly in 2000 by the U.S. Consumer Product Safety Commission (CPSC) and the Centers for Disease Control and Prevention to provide national-level estimates of the U.S. ED visits for nonfatal injuries (12). The NEISS collects de-identified injury data from approximately 100 EDs nationwide, allowing for querying injury records by product type, body part involved, or other variables. This study was exempted from the institutional review board as the investigation only involved publicly available data.
We analyzed NEISS data from January 1, 2005 through December 31, 2024, which are the dates currently available in the NEISS query system. We identified cases involving pediatric patients (aged 0-18 years) with TGOIs. Cases of toy gun-related injuries were identified using product code 1399 (“Toy guns with projectiles,” such as BB guns and dart guns). Among the identified cases, ones involving the eyeball (body part code 77) were included in the analysis. Variables collected included demographic information (age, sex, and race/ethnicity), treatment date, injury diagnosis, injury location, and disposition. Each case also included a narrative description that was reviewed to supplement any missing variables. Diagnoses based on the NEISS injury codes and narrative fields were recorded as categories by the author HNY.
The diagnosis was further classified into major anterior segment injuries (hyphema, corneal laceration, and traumatic cataract), minor anterior segment injuries (corneal abrasion, traumatic iritis/uveitis, contusion, conjunctivitis, conjunctival hemorrhage, and intraocular foreign body), major posterior segment injuries (ruptured globe), and minor posterior segment injuries (commotio retinae) (13). Moreover, to reflect diagnosis-based severity, the injuries were further categorized by an injury classification system for pediatric ocular injury (14). High severity included hyphema, corneal laceration, corneal abrasion, traumatic cataract, intraocular foreign body, and ruptured globe; medium severity, traumatic iritis/uveitis and contusion; and low severity, conjunctivitis and conjunctival hemorrhage. Injuries were also categorized by season based on the month of occurrence: spring (March-May), summer (June-August), fall (September-November), and winter (December-February).
National estimates were calculated using the weights assigned to each case by the NEISS. The estimates were excluded from reporting if they did not meet the CPSC criteria for data stability, which included having fewer than 1,200 weighted cases, fewer than 20 unweighted cases, or a coefficient of variation (CV) greater than 33%. CV were generated by the NEISS platform (square root of the variance divided by the estimate), and 95% confidence intervals were calculated using CV and based on the formula provided by the CPSC (estimate ± [1.96 × estimate × CV]) (15).
Descriptive statistics were used to characterize the distribution of injuries by age, sex, race/ethnicity, and diagnosis. Categorical variables were reported as frequencies and percentages, while continuous variables were presented as means with standard deviations. Trends were assessed across 4 time-intervals (2005-2009, 2010-2014, 2015-2019, and 2020-2024). Chi-square tests were used to analyze categorical measures, and one-way analysis of variance was employed for continuous measures to evaluate temporal changes. If an overall P value for comparison among the 4 time-interval groups is statistically significant (P < 0.05), post-hoc pairwise comparisons were performed with Bonferroni correction for multiple comparisons, and a P value of < 0.0083 was considered statistically significant. All statistical analyses were conducted using IBM SPSS ver. 29.0 (IBM Corp.).
Results
A total of 695 pediatric TGOI cases were identified in the 2005-2024 NEISS database, corresponding to a national estimate of 16,325 cases (95% confidence interval, 8,673-16,599). Males accounted for 77.4% of the study population (Table 1). The mean age reported from the TGOI cases was 9.1 ± 3.9 years. The injuries predominantly occurred in patients aged 7-12 years. Regarding race and ethnicity, non-Hispanic white patients accounted for 55.4%, followed by African American patients (16.8%). Regarding the location of injury, the majority of TGOI occurred at home (45.6%) (Table 1).
Specific diagnoses are summarized in Table 2. Cases of major and minor anterior segment injuries accounted for 22.6% and 52.1%, respectively. By severity, 57.3% of the cases were classified as the high severity. In terms of disposition, most cases (95.5%) ended up being discharged from EDs, while a smaller subset were transferred, hospitalized, or left without being seen (0.9%). Among 12 cases requiring hospitalization or observation, 8 were of hyphema, 2 of ruptured globe, and 2 of corneal laceration. The injuries occurred most commonly during the winter season (32.1%), followed by the spring (23.5%), summer (23.0%), and fall (21.4%) (Figure 1).
Temporal trends showed an increase in the reported cases over time, from 47 during 2005-2009 to 341 during 2020-2024 (Table 3, Figure 2). Correspondingly, the national estimates increased over time, from 1,425 during 2005-2009 to 1,562 during 2010-2014, 4,924 during 2015-2019, and 8,414 during 2020-2024. The number of pediatric ocular injuries related to home maintenance products remained consistent over the study period (e.g., bleach or cleaning chemicals) (Appendix, https://doi.org/10.22470/pemj.2025.01445). The mean age of affected children varied across the periods, ranging from 8.1 years during 2010-2014 to 9.6 years during 2020-2024 (P = 0.005) (Table 3). Post-hoc test showed the mean age during 2020-2024 was significantly higher than the mean ages in 2010-2014 and 2015-2019 (Bonferroni corrected P < 0.008). Home remained the most common venue (37.8%-63.8%) for TGOIs across the periods.
Discussion
This study presents the largest and most up-to-date analysis of pediatric TGOI in the U.S., based on 20 years of the NEISS data. Our findings offer critical insights into the demographics, injury types, and temporal trends of the injuries, with important public health and clinical implications.
The TGOI cases were more common in male patients, which may reflect gender-based differences in play behavior and risk exposure (16). Most injuries occurred in those aged 7-12 years, highlighting the vulnerability of this age group to TGOI. Children in this age range may be more likely to use toy guns independently or engage in more forceful play without adequate supervision or protective eyewear (17). This provides important insights into the group of children who may require special supervision to reduce the risk of TGOI.
TGOI was most common during winter, likely due to several overlapping factors. Holidays like Christmas increase toy gun ownership, as they are popular gifts. In addition, cold weather keeps children indoors, where close-range play in confined spaces raises the injury risk. The risk of TGOI may also be raised by the reduced supervision during winter breaks and the fact that most injuries occur at home. Parents, caregivers, and educators should establish clear safety rules, encourage protective eyewear, and closely supervise play, particularly during winter.
In this study, TGOI cases showed a broad clinical spectrum and occurred most frequently in the anterior segments of the globe as a form of minor injuries, such as corneal abrasions. Some injuries were more severe, with major anterior segment injuries such as hyphema comprising 22.6% of the cases. We observed that 1.7% of the cases required hospitalization due to hyphema, ruptured globe, or corneal laceration. These findings highlight that while many TGOIs may be minor in severity, a meaningful subset can be of a higher severity, echoing previous research on serious outcomes, including blindness and the need for surgical intervention (18).
A notable finding is the marked increase in reported cases over the study period, with a more than 7-fold rise from 2005-2009 to 2020-2024. This increasing trend in the TGOI cases may reflect the growing popularity of and accessibility to toy guns or changes in reporting practices. Given that NEISS national estimates for all ocular injuries or other product-related injuries in the U.S. did not show an increasing trend (19), the trend observed in our study may reflect a true increase in TGOI rather than an overall increase in the reporting of ocular injuries. The increase in the mean age of the injured patients over the period suggests that newer toy guns may be more appealing or accessible to older children or adolescents.
The distribution of injury types shifted over time, with hyphema becoming more frequent in recent years. The rise in severe anterior segment injuries is concerning, as these are associated with a higher risk of long-term visual sequelae, including glaucoma, re-bleeding, and vision loss (20,21). These trends may be influenced by changes in toy gun design, such as increased projectile velocity or the use of harder materials, as well as by evolving patterns of use and supervision (18).
The sharp increase in reported injuries over time underscores the urgent need for regulatory action and preventive strategies. Prior studies have shown that the vast majority of TGOI are preventable through the use of protective eyewear, age-appropriate toy selection, and adequate adult supervision (22). Public health campaigns and parental education should emphasize these measures, particularly among boys and children aged 7-12 years. Regulatory efforts to limit the velocity and hardness of toy gun projectiles may also be warranted (23).
While this study provides valuable insights into TGOI in the pediatric population, several limitations should be noted. The data only included visits to EDs. Many acute trauma cases may be treated elsewhere such as an ophthalmology clinic, potentially underestimating the true national incidence of TGOI. Due to the unavailability of data, we were unable to explore the types of toy guns, which may influence the nature and severity of injury. Moreover, there were substantial missing data, including race/ethnicity (21.9%), unspecified diagnoses (23.7%), and unknown injury locations (52.8%), which might have impacted subgroup analyses and overall interpretation of the results. Additionally, the NEISS database only captures initial ED visits, lacking information on follow-ups, long-term outcomes, detailed injury severity, treatment, or complications. This limits the ability to assess injury progression and visual outcomes over time.
Nonetheless, the large sample size and national representativeness provide robust evidence of a growing, preventable pediatric public health concern. The rising incidence, changing demographic patterns, and high proportion of severe injuries underscore the urgent need for enhanced prevention strategies, including education, regulation, and improved product safety standards. Clinicians should counsel families on the risks associated with projectile-based toys, and policymakers must consider revisiting safety standards to help prevent avoidable vision loss in children.
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